soap note

Name: M.A

Date: 04/11/2021

Time: 10:45 am

Age: 55

Sex: M

SUBJECTIVE

CC: “ Back pain after a fall from a ladder” 

HPI: 

Patient is a 55-year-old African American male, generally healthy, no change in strength or exercise tolerance. That present to the office for evaluation because 5 days ago he fell from a ladder 5 feet on the grass, received contusion on the back, denied loss of consciousness, paresthesia, dizziness, or vomiting. Now he's complaining about back pain 10/10.

Medications: Denies

PMH

Allergies:  Denies any allergies to food or medication 

Medication Intolerances: Denies.

Chronic Illnesses/Major traumas Normal childhood illness 

Hospitalizations/Surgeries: Denies

Family History

Mother: Deceased, heart attack

Father: alive, CAD, CHF.

Brothers: 1 Alive healthy.

Sister: 1 Alive healthy.

Social History

Patient is a truck driver, Married, sexually active Heterosexual, drinks alcohol occasionally. Patient denies any drugs consumption.

ROS

General

General Patient looks in good health no distress noted at this moment, responding question in an appropriated mood; patient denied any change in weight or energy levels. No change in strength or exercise tolerance.

Cardiovascular

Patient denies chest pain and palpitation. No edema noticed no syncope, no orthopnea.

Skin

Warm and dry, No rashes bruising or bleeding noticed, skin is appropriated color for ethnicity.

Respiratory

Patient without dyspnea, no wheezing, no hemoptysis, no cough or any acute distress at this moment. 

Eyes

Normal vision, denies blurred vision, diplopia, no vision loss, or pain.

Gastrointestinal

No change in appetite, no dysphagia denies heartburn or abdominal discomfort, denies nausea vomiting and diarrhea at this time. 

Ears

No change in hearing, no tinnitus, no bleeding, no vertigo. 

Genitourinary/Gynecological

Male patient denies bleeding, discharge or urinary symptoms (urgency, frequency burning, change in color of urine).

Nose/Mouth/Throat

Patient denies nasal congestion, sore throat or difficult to swallow. 

Musculoskeletal

Thoracic and Lower back Pain after fall (10/10) Pain Scale, no pain in joints, no limitation of range of motion, no paresthesia or numbness.

Breast

N/A

Neurological

No weakness, no tremor, no seizures, no change in mentation, no ataxia, and denies dizziness

Heme/Lymph/Endo

No bruises, hematomas, ecchymosis, lymph nodes or mass.

Psychiatric

Denies depression, symptoms, no change in sleep habits, any suicidal ideation or mood change.

OBJECTIVE

Weight 180.00 lbs   BMI 23.1

Temp 98.5 F

BP 130/85

Height 6.2 in

Pulse 86 bpm

Resp 18 bpm

General Appearance

Patient in pain, in no acute distress. Normal energy level.

Skin No pallor, jaundice, ecchymosis, or rash. Good skin turgor.

HEENT

Head is atraumatic and normocephalic. Eyes: PERRLA, EOM’s Full. No lesions on external ear, TM’S normal. Hair is evenly distributed. Lymph nodes are not palpable. Neck is supple and trachea in midline. Good dentition. Thyroid gland within normal limits for size and consistency. No cervical lymphadenopathy or mass.

Cardiovascular

Regular rhythm and rate.

No murmur, no rubs or gallop upon auscultation.

No peripheral edema

Respiratory

Lungs clear bilaterally upon auscultation, no rales, no rhonchi, and no wheezes.

Breath sounds equal, no rubs

Gastrointestinal

Abdomen no distends.

No hepatosplenomegaly, mass, or herniation

Abdomen Soft, non-tender throughout , BS normal in all 4 quadrants

Breast

Breast is free from masses or tenderness.

Genitourinary

Normal external genitalia, no palpable masses in the suprapubic area.

Musculoskeletal

Steady gait, no limping or musculoskeletal deformities. Back: normal external curvature, positive tenderness, Thoracic and lumbar spine, paravertebral muscle spasm. Extremities: ROM: wnl, no deformities.

Neurological

Reflexes 2+ bilaterally throughout

CN II-XII intact

Psychiatric

Good judgment, awake, alert and oriented answering questions.

Lab /Tests/Screening/Intervention/Assessment:

Spine Thoracic and Lumbar X-ray 2 views.

Adult depression Screening assessment.

Documentation of current medication.

Pain care documented

Special Tests

 Not performed

 Diagnosis

M54.9 | Dorsalgia, unspecified

M54.5 | Low back pain

Plan/Therapeutics

Plan:

Discussed compliance with medication.

Illness counselling.

Check blood pressure 3 times a week, for 2 weeks, record and bring in log.

Sing release consent form.

RCT or call if no improvement.

RTC in 2 weeks.

Medications:

1.- Cyclobenzaprine HCL10 mg tab: Take 1 tab (10mg) P/O 2 times per day as needed #30 NR.

2.- Ketorolac tromethamine 60 mg/2ml ing sol. Administer 2 ml (60mg) IM Stat.

3.- Tramadol HCL 50 mg oral tablet: take 1 tablet by mouth every 6 hours as needed #50 NR.

Treatment for back pain generally depends on whether the pain is acute or chronic. Conventionally used treatments and their level of supportive evidence include:

Hot or cold packs have never been proven to quickly resolve low back injury; however, they may help ease pain and reduce inflammation for people with acute, subacute, or chronic pain, allowing for greater mobility among some individuals.

Activity: Bed rest should be limited. Individuals should begin stretching exercises and resume normal daily activities as soon as possible, while avoiding movements that aggravate pain. Strong evidence shows that persons who continue their activities without bed rest following onset of low back pain appeared to have better back flexibility than those who rested in bed for a week. Other studies suggest that bed rest alone may make back pain worse and can lead to secondary complications such as depression, decreased muscle tone, and blood clots in the legs.

Strengthening exercises, beyond general daily activities, are not advised for acute low back pain, but may be an effective way to speed recovery from chronic or subacute low back pain. Maintaining and building muscle strength is particularly important for persons with skeletal irregularities. Evidence supports short- and long-term benefits of yoga to ease chronic low back pain.

Physical therapy programs to strengthen core muscle groups that support the low back, improve mobility and flexibility, and promote proper positioning and posture are often used in combinations with other interventions.

Medications: A wide range of medications are used to treat acute and chronic low back pain. Some are available over the counter (OTC). The following are the main types of medications used for low back pain: Analgesic medications are those specifically designed to relieve pain. They include OTC acetaminophen and aspirin, as well as prescription opioids such as codeine, oxycodone, hydrocodone, and morphine. Nonsteroidal anti-inflammatory drugs (NSAIDS) relieve pain and inflammation and include OTC formulations (ibuprofen, ketoprofen, and naproxen sodium). Anticonvulsants: may be useful in treating people with radiculopathy and radicular pain.

Reference:

Bethesda, M. 2. (December 2014). Low Back Pain Fact Sheet. National Institute of Neurological Disorders and Stroke.

 Evaluation of patient encounter

Interview process went well, practitioner elaborated the plan of care with patient, and education was provided and verbalized understanding.